APPOINTMENT OF HEALTH CARE REPRESENTATIVE
					and
			MEDICAL POWER OF ATTORNEY

 
 
I, YOURNAME, hereby appoint NAME, of
ADDRESS and PHONENUMBERS,    
to be my health care representative and to have medical power of attorney for me.
My representative is empowered to make any and all health care 
decisions for me if I become incapacitated and unable to make or
communicate my choices.  My representative is authorized to make
decisions to accept or to refuse any treatment, 
service or procedure used to diagnose or treat my physical or mental 
condition, and decisions to provide, withhold or withdraw life-sustaining 
treatment.

I direct my health care representative to make decisions on my behalf in
accordance with my wishes as stated in my Health Care Advance Directive
(attached), or as otherwise known to him or her.  In the event my wishes
are not clear, or if a situation arises that I did not anticipate, my
health care representative is authorized to make decisions in my best interests.

If the person I have designated above is unable, unwilling or unavailable 
to act as my health care representative, I hereby designate the following 
person to act as my health care representative:  NAME, ADDRESS and PHONENUMBERS.

This document is intended to serve as a Durable Health Care Power of Attorney.
This document is intended to be valid in any jurisdiction in which it is presented.
The powers delegated under this document are separable, so that invalidation
of one or more powers shall not affect any others.

My representative shall have access to my medical records and information
to the same extent that I am entitled to, including the right to disclose
the contents to others.  My representative is authorized to direct my admission
or discharge from any facility, to contract for health care services or
facilities, to hire and fire personnel responsible for my care, to authorize
or deny any medication or procedure.  My representative is authorized to
make anatomical gifts of part or all of my body for medical purposes,
authorize an autopsy, and direct the disposition of my remains.

My representative is authorized to grant any waiver or release from liability
required by any provider or facility in the course of my health care,
sign any documents required, and pursue any health-care-related legal action
in my name at the expense of my estate.  My representative shall not be
held personally liable for any action taken in my name.  No person who relies
in good faith upon any representations by my representative shall be liable
to me, my estate, or my heirs for recognizing my representative's authority.

My representative shall not be entitled to compensation for services performed
for me, but shall be entitled to reimbursement for all reasonable expenses
incurred in my service.

I direct that my health care representative comply with the
instructions and/or limitations specified in the attached
Health Care Advance Directive document.  By writing this advance
directive, I inform those who may become 
responsible for my health care of my wishes and intend to ease the 
burdens of decision making which this responsibility may impose. I have 
discussed the terms of this designation with my health care 
representative(s) and my representative(s) has/have willingly agreed to 
accept the responsibility for acting on my behalf in accordance with this 
directive and my wishes. I understand the purpose and effect of this 
document and sign it knowingly, voluntarily and after careful deliberation. 
 
Signed this _________ day of ______________________ 20 _________. 
 
Signature ___________________________________________________ 
 
Address ____________________________________________________ 
 
City _________________________________ State _________________ 
 
I declare that the person who signed this document or asked another to 
sign this document on his or her behalf, did so in my presence, that he or 
she appears to be of sound mind and free of duress or undue influence. I 
am 18 years of age or older, and am not designated by this or any other 
document as the person’s health care representative or alternate health 
care representative. 
 
1. Witness __________________________________________________ 
 
Address ____________________________________________________  
 
City __________________________________ State ________________ 
 
Signature & Date______________________________________________ 
 
2. Witness __________________________________________________ 
 
Address ____________________________________________________  
 
City _________________________________ State _________________ 
 
Signature & Date ________________________________________